Background: Thoracic endovascular aortic repair (TEVAR) represents optimal therapy for complicated acute type B aortic dissection (aTBAD). Persistent knowledge gaps remain, including optimal length of aortic coverage, impact on distal aortic remodeling, and fate of the dissected abdominal aorta.
Methods: Review of the Emory Aortic Database identified 92 patients who underwent TEVAR for complicated aTBAD from 2012-2018. Standard TEVAR covered aortic zones 3 and 4 (from the left subclavian to the mid-descending thoracic aorta). Extended TEVAR fully covered aortic zones 3 though 5 (from the left subclavian to the celiac artery). Long-term imaging, clinical follow-up, overall and aortic-specific mortality were reviewed.
Results: Extended TEVAR (n=52) required a greater length of coverage vs. Standard TEVAR (n=40) (240±32mm vs. 183±23mm, p<0.01). In-hospital mortality occurred in 5.4% (7.7% vs. 2.5%, p=0.27) due to mesenteric malperfusion (n=3) or rupture (n=2). Overall incidence of postoperative stroke, transient paraparesis, paraplegia, and dialysis were 5.4% (3.9% vs. 7.5%, p=0.38), 3.2% (5.8% vs. 0%, p=0.18), 0%, and 0% respectively, equivalent between groups. Follow-up was 96.6% complete to a mean of 6.1 years (interquartile range 3.5-8.6 years). There were significantly higher rates of complete thrombosis/obliteration of the entire thoracic false lumen after Extended TEVAR (82.2% vs. 51.5% p=0.04). Distal aortic reinterventions were less frequent after Extended TEVAR (5.8% vs 20%, p=0.04). Late aorta-specific survival was 98.1% after Extended TEVAR vs. 92.3% for Standard TEVAR (p=0.32).
Conclusion: Extended TEVAR for complicated aTBAD is safe, results in a high rate of total thoracic false lumen thrombosis/obliteration, and reduces distal reinterventions. Longer-term follow-up will be needed to demonstrate a survival benefit compared to limited aortic coverage.
Keywords: Aortic Dissection; Reintervention; Remodeling; Thoracic Endovascular Aortic Repair (TEVAR).
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